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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200313
Report Date: 02/20/2025
Date Signed: 02/20/2025 11:36:27 AM

Document Has Been Signed on 02/20/2025 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ARCYAN CARE HOMEFACILITY NUMBER:
019200313
ADMINISTRATOR/
DIRECTOR:		MARCY DELA CRUZFACILITY TYPE:
735
ADDRESS:172 TAMARACK DRIVETELEPHONE:
(510) 928-2650
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Marcy dela CruzTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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On this day at around 9:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Amanda Grafia. LPA explained to Grafia the purpose of the visit. The Administrator arrived at the facility at around 10am.

Upon arrival, LPA observed 1 staff and 3 clients. Grafia states one client is currently in the hospital.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB). LPA observed fire extinguisher that appeared full and was last serviced on 3/12/2024 . Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet in the hallway. Hot water measured at 113 Fahrenheit.

At around 9:45 am, LPA reviewed 2 staff and 4 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. At 10:30 am, P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time. At around 10:40 am, LPA reviewed medications and Medications Administration Records (MAR) with Grafia. The facility's last fire drill was conducted on 12/5/24 and last earthquake drill was completed on 1/6/25.

At around 9:30 am, LPA observed Comet cleanser and a pair of scissors unlocked in the kitchen.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted with Grafia and a copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 11:36 AM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/20/2025 at 11:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ARCYAN CARE HOME
FACILITY NUMBER: 019200313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having Comet cleanser and a pair of scissors unlocked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Staff locked cleanser and scissors during the visit. This deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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